20 Apr Legislator trying to learn fate of three heart patients

Deleware Online | Early last year, four Delaware patients needed emergency heart-related procedures only days after Blue Cross Blue Shield of Delaware refused to pay for a nuclear cardiac stress test to measure blood flow to the heart, according to results of a state investigation.

But the final outcome is known for only one of those patients — Michael Fields, the 46-year-old Maryland man whose story of successful emergency bypass surgery reported in The News Journal in March 2010 triggered state and federal investigations of preauthorization denials by insurers.

A legislator in Dover is now pressing to know what happened to the other three patients.

“There’s a part of this report that’s missing,” said Rep. Danny Short, R-Seaford. “Did the patients get the treatment they needed? Did they survive? Are they back at work? Let’s get personal on this and find out truly what the outcome was.”

Citing patient privacy, BCBSD would not comment on the outcomes of the four patients who ended up hospitalized after a preauthorization for the critical test was denied.

In its report published Friday, Delaware’s Department of Insurance said BCBSD, through a Tennessee-based contractor, denied 27 percent of Delaware doctors’ requests for nuclear cardiac scans from July 2009 to April 2010. State investigators found that 12 percent of the preauthorization denials were inappropriate.

The program, administered by a company called MedSolutions, forced doctors to prove why a test was necessary before the insurer would agree to pay. The state probe concluded that the strict criteria for approval used by MedSolutions made it difficult for high-risk patients such as Fields to access needed diagnostic exams.

Part of MedSolutions’ fee was based on the company’s reaching a predetermined target of denying 20 percent of preauthorization requests, a contract provision that violated state law, the report said.

On Monday, Sen. John D. Rockefeller, D-W.Va., whose office led a separate probe of pre-authorization programs at BCBSD and Aetna in Delaware, strongly criticized the program.

“Too many Americans who need life-saving tests don’t get them,” said Rockefeller, who chairs the Senate Committee on Commerce, Science and Transportation. “That’s because health insurance companies employ third-party companies to deny tests that are costly and would hurt their bottom line. This practice is putting profits over people — and putting lives at risk.”

BCBSD said federal privacy laws prevent the company from commenting on the individual cases, first noted in the Department of Insurance’s report, which took 13 months to complete and examined BCBSD claims data in detail.

According to the report, the four patients could have undergone procedures such as heart-bypass surgery, or a cardiac catheterization, during which a doctor threads a catheter into blood vessels around the heart to diagnose disease. Doctors also use catheterization procedures to insert stents that prop open clogged arteries.

One patient was denied a nuclear scan on Jan. 4, 2010, only to submit a serious cardiac claim two days later. Another submitted a heart-related claim five days after his denial. Another needed emergency attention 16 days after a denial.

Fields pleaded with BCBSD and MedSolutions for test approval for 33 days before doctors admitted him into the emergency department at Christiana Care. In the days leading up to his hospitalization, he was experiencing lightheadedness and chest pressure he described as feeling like a balloon was inflating inside his chest. In phone calls, Fields told insurance company representatives that he feared for his life.

Dr. Bruce Turner, a Newark-based family physician who ordered Fields’ tests, criticized BCBSD for allowing a third party to make claims decisions; he suggested the insurer was attempting to shift blame for bad decisions.

“The insurance companies are outsourcing to a company who should or should not get a test. That’s crooked,” Turner said.

Insurance Commissioner Karen Weldin Stewart’s office launched its probe of BCBSD in March 2010, after The News Journal published a series of stories detailing how BCBSD and MedSolutions were refusing to pay for heart scans patients’ doctors said were needed.